Conference Coverage

Debate: After methotrexate failure, is JAK inhibitor or biologic next?



Differences in cost?

“We have not benefited yet from the biosimilar costs. But in Europe, the cost of an adalimumab or etanercept biosimilar is about $5,000, versus about $50,000 to $60,000 in the U.S. for the JAK inhibitors,” Dr. Weinblatt said. “So there are major cost savings with biosimilars.”

“I can’t understand cost at all for our drugs,” he continued. “They’re not rational, and the price increases are clearly not rational. Potentially, a small molecule is going to be a lot easier to produce than a biologic, so you could argue that generic jakinibs ought to be less. But in the United States we have a distorted pricing model.”

“Until that changes, I don’t think we can predict [future costs]. One could predict that generics and biosimilars will be less than the orginators,” Dr. Weinblatt said.

“It is really criminal we don’t have biosimilars for most of our TNFs, but that is the way it is,” Dr. Strand said.

Summary statements

“The JAK-inhibitor class is an exciting development for rheumatology and a broad variety of autoimmune diseases,” Dr. Strand said.

“In rheumatoid arthritis, they should be used early,” she added. “Based on phase 3 trials, responses are better in progressively earlier disease with less treatment-experienced patients.”

She pointed out that many patients like the convenience of the oral JAK inhibitors.

Dr. Weinblatt stated the 22 years of clinical experience with the anti-TNF class versus about 8 years with jakinibs favors the biologics. “Virtually every approved drug has been tested versus methotrexate, in early studies, long-term studies, and most importantly, in reduction and withdrawal studies, which are not available with the JAK inhibitors.”

Anti-TNFs have impressive effects on clinical disease activity, functional outcomes, and radiographic progression, Dr. Weinblatt said. They work in early and longstanding disease among patients who are disease-modifying antirheumatic drug naive and after multiple DMARD failures, he added.

Adding up the vote

The question was: Should JAK inhibitors be used before TNF inhibitors? The results showed 69%-31% in favor of anti-TNF agents.

“So the majority are more comfortable using TNFs,” said debate moderator Elizabeth Wahl, MD, of the department of rheumatology at VA Puget Sound Healthcare System and the University of Washington in Seattle. Regarding a switch to JAK inhibitors, she interpreted the poll numbers to mean, “we are not there yet, it takes years and years of safety data.”

Both Dr. Strand and Dr. Weinblatt disclosed numerous financial relationships with pharmaceutical companies that market RA drugs.


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